Tribute Advantage (HMO-POS D-SNP)

Medicare Plan Details (2023 Plan)


Monthly Premium

 

by Tribute Health Plans
Additional Coverage
HearingVisionDental
Overall Government Star Rating
No Rating (new plans)
out of 5 stars

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Plan Type

Medicare Advantage (Part C) with Prescription Drug (Part D)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D

 

$0
$0
$0
$0
$8,300 In-network
No
Yes
Yes
Yes

Doctor Services

In-network: $0 copay
Out-of-network: 20% coinsurance per visit
In-network: $0 copay
Out-of-network: 20% coinsurance per visit

Tests, labs, & imaging

In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance
$0 copay
$0 copay

Hospital Services

In-network: $0 copay
Out-of-network: In 2023 the amounts for each benefit period are:
$1,600 deductible for days 1 through 60
$400 copay per day for days 61 through 90
In-network: $0 copay
Out-of-network: 20% coinsurance per visit

Skilled nursing facility

In-network: $0 copay
Out-of-network: In 2023 the amounts for each benefit period are:
$0 copay for days 1 through 20
$200 copay per day for days 21 through 100

Preventive services

In-network: $0 copay
Out-of-network: 20% coinsurance

Ambulance

In-network: $0 copay
Out-of-network: 20% coinsurance

Therapy services

In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance

Mental health services

In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance

Opioid treatment services

Covered

Other services

In-network: $0 copay
Out-of-network: 20% coinsurance per item
In-network: $0 copay
Out-of-network: 20% coinsurance per item
In-network: $0 copay
Out-of-network: 20% coinsurance per item

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseGap coverage phaseCatastrophic coverage phase
Preferred Generic


Generic drugs :
25%

Brand-name drugs :
25%


Generic drugs :
$4.15 copay or 5% (whichever costs more)

Brand-name drugs :
$10.35 copay or 5% (whichever costs more)

Generic
Preferred Brand
Non-Preferred Drug
Specialty Tier

Part B Drugs

In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance

Hearing

In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data

Preventive Dental

In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data

Comprehensive dental

In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data

Vision

In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data

Other benefits

Not covered
Limited coverage
Not covered
Not covered
Limited coverage
Not covered
Limited coverage
No Rating (new plans)
No Rating (new plans)
 4
No Rating (new plans)
 5
No Rating (new plans)
 4
 5
 4
No Rating (new plans)
 4

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